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0 <br /> APITyr TO N TO ffop SeffeloConsent to Tattoo Release and Li ill Waiver d ffflalms <br /> The questions and responses shall be considered confidential information.this body art facility shall maintain the privacy of the <br /> Information and shall not sell,share or transfer any information. <br /> 1. Are you 18 or older? <br /> 2. Are you diabetic?- A Hemophiliac? or have any other bleeding dlsorder?_ <br /> 3. Are you under the influence of drugs or alcohol? <br /> 4. Have you eaten In the last 4-6 hours? <br /> S. Are you taking any prescription drugs?_if so,please consult your phVsklan before recWhft Ink <br /> 1a". Do you have any known allergies?_if yes,type of allerW, <br /> 7. Have you ever been tested positive for HIV,AIDS virus,or Hepatitis(any strain)?_if so,please <br /> B. Have you ever had herpes,any other skin infections or disorders In the area being worked on? N yes please <br /> consult your physician before receiving your tattoo. <br /> I agree to the following: <br /> 1. 1 acknowledge that it is not possible for the artist or employees at Forever Yours Tattoo Studio to determine whether or not I might <br /> have an affergic reaction to any of the materials used during the procedure.I accept the risk that a reaction is possible,and will not <br /> hold forever Yours Tattoo Studio artists or employees responsible if a reaction should occur. <br /> 2. 1 acknowledge that aftercare instructions have been given to me and have no further questions. <br /> 3. 1 acknowledge that infection is always possible in the event I do not property care for my tattoo,and will not hold Forever Yours Tattoo <br /> Studio,its employees or anyone associated with Forever Yours liable for any problems or any expenses that does occur rf any infection <br /> should arise. <br /> 4. J agree to hold harmless Forever Yours Tattoo Studio,its emplayeesp or anyone associated with Forever Yours from all claims or legal <br /> action arising from or connected to the tattoo,in any way related to the tattoo or the procedure sand conduct used during the,tattoo. <br /> 5. /acknowledge by signing this fora: that all of the information on this release is true and correct.I am obtaining my tattoo of my own <br /> free will and that all of my questions have been answered to my satisfaction. <br /> dame <br /> DOB <br /> Address <br /> Phone#L_) <br /> 0 check here V you agree to all to and cmdidons <br /> Signature to <br /> k) <br /> ® Wis reaulredat the time of tattoo: Fre'CetjUr-C OPI <br />